telehealth: legal and compliance issues - hcca official site€¦ · telehealth compliance...

1

1

Nathaniel LacktmanPartnerFoley & LardnerFoley.com/telemedicine

Telehealth: Legal and Compliance Issues

April 20, 2015

2

Telehealth

Licensure•in-state

•across states•international

Credentialing

Scope of Practice•consult

•diagnose•treatment recs

•prescription

Operational

Privacy & Security

•HIPAA HITECH•record

requirements•state law

Reimburse-ment

•commercial•Medicare•Medicaid•self-pay

Business Models

Professionals•alignment•affiliations

•fraud & abuse• liability

International

Telehealth Legal Considerations

Sample Business Models

1. Direct-to-patient/consumer

2. Institution-to-institution

3. Clinician-to-clinician consulting

4. Internal oversight and processes

5. Chronic care management

6. Online patient access/portals/tech

7. mHealth, medical apps

8. Hardware/software

3

Business Models

2

Sample Arrangements

1. DTC urgent care access2. Telestroke PSA with critical access hospital3. Peer-to-peer specialty consulting services4. eICU5. Follow-up visits/consults for existing patients

(e.g., post-op, mental health, chronic disease)6. Online second opinions7. Self-tracking apps and diagnostics8. On-site kiosks (schools, factories, oil rigs)9. International (e.g., U.S. to China telemedicine)

4

Business Models

Sources of Compensation

• Government

• Commercial Plans (incl. MMC, MA)

• Employer-pay (incl self-funded plans)

• Org-to-org, peer-to-peer

• Patient self-pay

• Cost savings

5

Business Models

Compensation Models

• FFS

• Capitated

• Shared savings, risk-based

• Hybrid models

6

Business Models

3

Telehealth Arrangements

• Fraud & Abuse Concerns

– Anti-kickback Statute

– Physician Self-referral

– Civil Monetary Penalty

– State Laws

• Fee-Splitting

• Patient Brokering

• Corporate Practice of Medicine

• Insurance Laws

7

Professionals•credentialing

•alignment•affiliations

•Fraud & Abuse

Operational Considerations

• Informed Consent

• Patient Choice of Provider

• Malpractice Considerations

• Record Keeping

• Nature of Exam and Technology Requirements

• Privacy & Security

8

Operational

Telemedicine Credentialing

9

Credentialing

Originating Site Hospital

Distant Site Hospital

Services + Credentialing

Payment + Reporting

4


• Written agreement between the two parties• Provisions in Bylaws• Distant-site hospital is a Medicare-participating hospital or telemedicine

entity• The professional is privileged at the distant-site hospital;• A current list of the professional’s privileges is given to the originating-

site hospital;• The professional holds a license issued or is recognized by the state in

which the originating-site hospital is located;• The originating-site hospital has an internal review of the professional’s

performance and provides this information to the distant-site hospital;• The originating-site hospital must inform the distant-site hospital of all

adverse events and complaints regarding the services provided by the professional.

10

Credentialing


• Medicare– Conditions of Participation

482.12; 482.22(a)(3); 485.616(c); 485.635; 485.641(b)(4)

– State Operations Manual

– CMS Memorandum

• Joint Commission Standards– LD.04.03.09; MS.13.01.01

• State Board of Medicine

11

Credentialing

Telehealth is Not Scary!

12

5

Nathaniel Lacktman

Foley & Lardner LLP

813.225.4127

[email protected]

www.Foley.com/telemedicine

13

SAMPLE CHECKLIST ONLY – FOR EDUCATIONAL PURPOSES/DOES NOT CONSTITUTE LEGAL ADVICE©2015 Foley & Lardner LLP • Attorney Advertisement • Prior results do not guarantee a similar outcome • 100 North Tampa Street, Tampa, Florida 33602 • 813-225-4127

Prepared by: Nathaniel Lacktman, Esq. [email protected]/nlacktmanFoley.com/telemedicine

Professionals

□ Are the telehealth professionals licensed in the

state where patient located?

□ Are there practice standards for patient

examinations and remote prescribing?

□ Are professionals documenting and maintaining

patient records of the encounters?

□ Does insurance policy cover telehealth services?

□ Is insurance carrier licensed in every state where

services are provided (patient located)?

Medicare/Medicaid

□ Do services qualify as covered telehealth services?

□ Are services being coded to properly reflect the

place of service?

□ Is the telehealth service provider located

internationally?

Commercial Insurance, Medicare Advantage, and Medicaid Managed Care

□ Does the state require commercial coverage of

services provided via telehealth?

□ Does the provider’s contracts reflect said coverage

and include negotiated payment amounts?

□ Has reimbursement other than FFS been

evaluated, such as PMPM, capitation add-ons, or hybrid risk-bearing?

Consent

□ Does the informed consent form account for

services provided via telehealth?

□ Does is recognize patient freedom of choice?

Fraud & Abuse

□ If Medicare/Medicaid, does the arrangement

comply with the federal Anti-Kickback Statute? (Check provider/vendor arrangements and patient incentive programs)

□ If Medicare/Medicaid, does the arrangement

comply with the federal Civil Monetary Penalties Law? (Check provider/vendor arrangements and patient incentive programs)

□ Does the arrangement comply with the Stark

Law? (Check all physician benefits, including software and equipment tech, to ensure they meet a Stark exception)

□ Does the arrangement comply with state patient

brokering laws and anti-kickback statutes? (Check provider/vendor arrangements and patient incentive programs)

□ Does the arrangement comply with state corporate

practice of medicine rules? (Check not just where the brick & mortar facility is located, but where the patients are located)

□ If capitated or PMPM compensation, does the

arrangement comply with state insurance laws? (Check if exempt and, if not, conduct risk assessment)

Credentialing

□ Is there a credentialing by proxy agreement in

place that meets all the elements?

□ Does the hospital relying on proxy credentialing

have such provisions in its bylaws?

□ Are the hospitals engaging in periodic

recredentialing assessments and reporting?

Privacy & Security

□ Are there privacy and security protocols for the

telehealth offerings?

Telehealth Compliance Checklist

SAMPLE ONLY – FOR EDUCATIONAL PURPOSES/DOES NOT CONSTITUTE LEGAL ADVICE

©2015 Foley & Lardner LLP • Attorney Advertisement • Prior results do not guarantee a similar outcome • 100 North Tampa Street, Tampa, Florida 33602 • 813-225-4127

Prepared by: Nathaniel M. Lacktman, Esq., [email protected]/nlacktmanFoley.com/telemedicine

TELEMEDICINE CREDENTIALING AGREEMENT

THIS TELEMEDICINE CREDENTIALING AGREEMENT is entered into and effective as of the ___ day of _______________, 201__ (“Effective Date”), by and between _______________ (“Service Provider”), and _______________ (“Service Recipient”).

WHEREAS, Service Provider is a Medicare-participating acute care hospital in the State of _______; and

WHEREAS, Service Recipient is a Medicare-participating critical access hospital in the State of _______; and

WHEREAS, Service Recipient desires to engage Service Provider to provide certain health care services via telemedicine, and the parties have entered into a Telemedicine Professional Services Agreement dated _____ to that effect; and

WHEREAS, the parties desire to ease the burdensome credentialing and privileging process relating to telemedicine providers by establishing a telemedicine credentialing and privileging process that meets the requirements of the Centers for Medicare and Medicaid Services (“CMS”), The Joint Commission (“TJC”), and applicable state and federal laws.

NOW, THEREFORE, in consideration of the mutual covenants and agreements of the parties hereto, it is understood and agreed by the parties as follows:

I. Definitions

As used in this Telemedicine Credentialing Agreement, the following terms, when capitalized, shall have the following meanings:

A. “Credentialing” means the evaluation and verification of Telemedicine Providers’ qualifications and competence to provide Telemedicine Services.

B. “Credentialing Program” means the process by which Telemedicine Providers’ qualifications and competence are evaluated and verified.

C. “Originating Site” means the site where patients are physically located when receiving the Telemedicine Services, namely Service Recipient’s location.

D. “Distant Site” means the hospital at which Telemedicine Providers have been granted clinical privileges to perform Telemedicine Services, namely Service Provider’s location.




2

E. “Telemedicine Provider” means a duly qualified, credentialed and privileged health care professional who holds a license issued or recognized by the State where the Originating Site is located, and is employed by or under contract with Service Provider to provide Telemedicine Services.

F. “Telemedicine Services” means the clinical services provided by Telemedicine Providers, under the Telemedicine Professional Services Agreement, to patients at the Originating Site via telemedicine technologies.

II. Service Provider Responsibilities:

A. Compliance with Conditions of Participation and TJC Standards. Service Provider is a Medicare-participating hospital. Service Provider’s Credentialing Program has been reviewed and approved by its governing body, and meets or exceeds all applicable Medicare Conditions of Participation related to Credentialing and the Telemedicine Services, including but not limited to the requirements at 42 C.F.R. § 485.616(c)(1) through (c)(1)(vii), and all applicable requirements in the Medical Staff chapter of TJC’s Comprehensive Accreditation Manual for Hospitals, including, but not limited to, MS.06.01.01 through MS.06.01.13. Specifically, the governing body of the Service Provider Distant Site, through its Credentialing Program, shall:

a. Determine, in accordance with State law, which categories of practitioners are eligible candidates for appointment to the medical staff;

b. Appoint members of the medical staff after considering the recommendations of the existing members of the medical staff;

c. Assure that the medical staff has bylaws;d. Approve medical staff bylaws and other medical staff rules and regulations;e. Ensure that the medical staff is accountable to the governing body for the

quality of care provided to patients;f. Ensure the criteria for selection are individual character, competence, training,

experience, and judgment; andg. Ensure that under no circumstances is the accordance of staff membership or

professional privileges in the hospital dependent solely upon certification, fellowship or membership in a specialty body or society.

B. Credentialing. Service Provider shall evaluate and, if appropriate, approve privileges and credentialing applications for practitioners at Service Provider who may provide Telemedicine Services.

a. Service Provider shall provide to Service Recipient a current list of privileges for each Telemedicine Provider who is seeking or has obtained telemedicine privileges at Service Recipient.




3

b. Upon reasonable request and subject to State law limitations, Service Providershall provide Service Recipient with a copy of its bylaws and medical staff rules and policies related to credentialing and peer review, as reasonable evidence of Service Provider’s compliance with Section II(A), above.

c. Upon reasonable request and subject to State law limitations, Service Providershall provide Service Recipient with the complete credentialing and privileging file for each Telemedicine Provider who is covered by this Telemedicine Credentialing Agreement.

C. Recredentialing. Service Provider shall conduct recredentialing of the Telemedicine Providers in accordance with its established policies and procedures, applicable Medicare Conditions of Participation, and applicable TJC standards, and will include in its recredentialing process information provided to Service Provider by Service Recipient.

D. Changes in Privileges; Disciplinary Action. Service Provider shall notify Service Recipient as soon as reasonably practicable of any change in privileges of a Telemedicine Provider who is providing Telemedicine Services to Service Recipient, and shall notify Service Recipient of any action classified as disciplinary action under applicable Service Provider policies taken against a Telemedicine Provider.

III. Service Recipient Responsibilities:

A. Credentialing by Proxy. The governing body and the medical staff of Service Recipient may choose to rely upon Service Provider’s Credentialing Program decisions when making its own credentialing and privileging decisions regarding the Telemedicine Providers. To that end, the governing body of Service Recipient shallensure compliance with the requirements at 42 C.F.R. § 485.616(c)(2) and Standards LD.04.03.09 of TJC’s Comprehensive Accreditation Manual for Hospitals. Service Recipient shall ensure that each Telemedicine Provider holds a license issued or recognized by the State where the Originating Site is located. Service Recipient shall ensure the privileges it grants each Telemedicine Provider at Originating Site do not exceed the privileges granted to that Telemedicine Provider at Service Provider.

B. Originating Site Performance Information. Service Recipient shall maintain evidence of its internal reviews of each Telemedicine Provider’s performance and quality at Originating Site and shall provide such performance and quality information to Service Provider for Service Provider’s periodic appraisals of the Telemedicine Providers, in accordance with 42 C.F.R. § 485.616(c)(2)(iv). At a minimum, this performance and quality information shall include all adverse events that result from the Telemedicine Services provided by each Telemedicine Provider to Service




4

Recipient’s patients and all complaints Service Recipient has received about each Telemedicine Provider (including but not limited to adverse outcomes related to sentinel events that are considered reviewable by TJC). Service Recipient shall notify Service Provider as soon as reasonably practicable of any action taken against a Telemedicine Provider by Service Recipient which is classified as disciplinary under Service Recipient’s credentialing policies.

C. State and/or Federal Disciplinary Action. Service Recipient shall notify Service Provider as soon as reasonably practical of any action taken by a state or federal authority which restricts or limits the practice or professional prerogatives of a Telemedicine Provider in Service Recipient’s State, including an involuntary suspension, termination, involuntary change or reduction in licensure status.

IV. Notices. All notices, requests and other correspondence related to telemedicine credentialing, medical staff membership or privileges between the parties related to this Telemedicine Credentialing Agreement shall be addressed to the credentialing offices of Service Recipient and Service Provider.

V. Term and Termination. This Telemedicine Credentialing Agreement shall commence on the Effective Date and shall continue unless terminated as provided for herein.

a. Without Cause. Either party may terminate this Telemedicine Credentialing Agreement at any time, without cause on ___ (___) days’ prior written notice to the other party, which notice shall specify the effective date of termination.

b. Mutual Consent. The parties may terminate this Telemedicine Credentialing Agreement at any time by mutual written consent of both parties.

c. Automatic Termination. In the event the parties’ Telemedicine Professional Services Agreement terminates, expires or otherwise ceases, this Telemedicine Credentialing Agreement shall automatically and concurrently terminate.

IN WITNESS WHEREOF, the parties have caused this Telemedicine Credentialing Agreement to be executed as of the Effective Date.

SERVICE PROVIDER

By: _________________________________Name: ______________________________Title: ______________________________

SERVICE RECIPIENT

By: _________________________________Name: ______________________________Title: ______________________________




5

EXHIBIT A

Telemedicine Providers

The following Telemedicine Providers have been assigned to provide Telemedicine Services for Service Recipient. A Telemedicine Provider may not begin providing Telemedicine Services for Service Recipient until Service Recipient has granted clinical privileges in accordance with its medical staff process.

Name Credentialed Services

This Exhibit A shall be updated throughout the term of this Telemedicine Credentialing Agreement as new Telemedicine Providers are engaged by Service Provider to perform Telemedicine Services for Service Recipient or as existing Telemedicine Providers terminate their engagement with Service Provider or no longer perform Telemedicine Services for Service Recipient.

Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of MedicineApril 2014

Federation of State Medical Boards | www.fsmb.org 2

MODEL POLICY FOR THE APPROPRIATE USE OF TELEMEDICINE TECHNOLOGIES IN THE PRACTICE OF MEDICINE

Report of the State Medical Boards’ Appropriate Regulation of Telemedicine (SMART) Workgroup

INTRODUCTION

The Federation of State Medical Boards (FSMB) Chair, Jon V. Thomas, MD, MBA, appointed the State Medi-cal Boards’ Appropriate Regulation of Telemedicine (SMART) Workgroup to review the “Model Guidelines for the Appropriate Use of the Internet in Medical Practice” (HOD 2002)1 and other existing FSMB policies on telemedicine and to offer recommendations to state medical and osteopathic boards (hereinafter referred to as “medical boards” and/or “boards”) based on a thorough review of recent advances in technology and the appropriate balance between enabling access to care while ensuring patient safety. The Workgroup was charged with guiding the development of model guidelines for use by state medical boards in evaluating the appropriateness of care as related to the use of telemedicine, or the practice of medicine using electronic communication, information technology or other means, between a physician in one location and a patient in another location with or without an intervening health care provider.

This new policy document provides guidance to state medical boards for regulating the use of telemedicine technologies in the practice of medicine and educates licensees as to the appropriate standards of care in the delivery of medical services directly to patients2 via telemedicine technologies. It is the intent of the SMART Workgroup to offer a model policy for use by state medical boards in order to remove regulatory bar-riers to widespread appropriate adoption of telemedicine technologies for delivering care while ensuring the public health and safety.

In developing the guidelines that follow, the Workgroup conducted a comprehensive review of telemedicine technologies currently in use and proposed/recommended standards of care, as well as identified and con-sidered existing standards of care applicable to telemedicine developed and implemented by several state medical boards.

1 The policy on the Appropriate Use of Telemedicine Technologies in the Practice of Medicine supersedes the Model Guidelines for the Appropriate Use of the Internet in Medical Practice (HOD 2002).

2 The policy does not apply to the use of telemedicine when solely providing consulting services to another physician who maintains the physician-patient relationship with the patient, the subject of the consultation.



3 See Center for Telehealth and eHealth Law (Ctel), http://ctel.org/ (last visited Dec. 17, 2013).

4 Id.

5 See Cal. Bus. & Prof. Code § 2290.5(d).

Model Guidelines for State Medical Boards’ Appropriate Regulation of Telemedicine

Section One. Preamble

The advancements and continued development of medical and communications technology have had a profound impact on the practice of medicine and offer opportunities for improving the delivery and accessibility of health care, particularly in the area of telemedicine, which is the practice of medicine using electronic communication, information technology or other means of interaction between a licensee in one location and a patient in another location with or without an intervening healthcare provider.3 However, state medical boards, in fulfilling their duty to protect the public, face complex regulatory challenges and patient safety concerns in adapting regulations and standards historically intended for the in-person provision of medical care to new delivery models involving telemedicine technologies, including but not limited to: 1) determining when a physician-patient relationship is established; 2) assuring privacy of patient data; 3) guaranteeing proper evaluation and treatment of the patient; and 4) limiting the prescribing and dispensing of certain medications.

The [Name of Board] recognizes that using telemedicine technologies in the delivery of medical services offers potential benefits in the provision of medical care. The appropriate application of these technologies can en-hance medical care by facilitating communication with physicians and their patients or other health care provid-ers, including prescribing medication, obtaining laboratory results, scheduling appointments, monitoring chronic conditions, providing health care information, and clarifying medical advice.4

These guidelines should not be construed to alter the scope of practice of any health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law. In fact, these guidelines support a consistent standard of care and scope of practice notwithstanding the delivery tool or busi-ness method in enabling Physician-to-Patient communications. For clarity, a physician using telemedicine tech-nologies in the provision of medical services to a patient (whether existing or new) must take appropriate steps to establish the physician-patient relationship and conduct all appropriate evaluations and history of the patient consistent with traditional standards of care for the particular patient presentation. As such, some situations and patient presentations are appropriate for the utilization of telemedicine technologies as a component of, or in lieu of, in-person provision of medical care, while others are not.5

The Board has developed these guidelines to educate licensees as to the appropriate use of telemedicine tech-nologies in the practice of medicine. The [Name of Board] is committed to assuring patient access to the conve-nience and benefits afforded by telemedicine technologies, while promoting the responsible practice of medicine by physicians.

It is the expectation of the Board that physicians who provide medical care, electronically or otherwise, maintain the highest degree of professionalism and should:

• Place the welfare of patients first;• Maintain acceptable and appropriate standards of practice;



• Adhere to recognized ethical codes governing the medical profession;• Properly supervise non-physician clinicians; and• Protect patient confidentiality.

Section Two. Establishing the Physician-Patient Relationship

The health and well-being of patients depends upon a collaborative effort between the physician and patient.6

The relationship between the physician and patient is complex and is based on the mutual understanding of the shared responsibility for the patient’s health care. Although the Board recognizes that it may be difficult in some circumstances to precisely define the beginning of the physician-patient relationship, particularly when the physi-cian and patient are in separate locations, it tends to begin when an individual with a health-related matter seeks assistance from a physician who may provide assistance. However, the relationship is clearly established when the physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees to be treated, whether or not there has been an encounter in person between the physician (or other appropriately supervised health care practitioner) and patient.

The physician-patient relationship is fundamental to the provision of acceptable medical care. It is the expecta-tion of the Board that physicians recognize the obligations, responsibilities, and patient rights associated with establishing and maintaining a physician-patient relationship. A physician is discouraged from rendering medi-cal advice and/or care using telemedicine technologies without (1) fully verifying and authenticating the location and, to the extent possible, identifying the requesting patient; (2) disclosing and validating the provider’s identity and applicable credential(s); and (3) obtaining appropriate consents from requesting patients after disclosures regarding the delivery models and treatment methods or limitations, including any special informed consents regarding the use of telemedicine technologies. An appropriate physician-patient relationship has not been es-tablished when the identity of the physician may be unknown to the patient. Where appropriate, a patient must be able to select an identified physician for telemedicine services and not be assigned to a physician at random. Section Three. Definitions

For the purpose of these guidelines, the following definitions apply:

“Telemedicine” means the practice of medicine using electronic communications, information technology or other means between a licensee in one location, and a patient in another location with or without an intervening healthcare provider. Generally, telemedicine is not an audio-only, telephone conversation, e-mail/instant mes-saging conversation, or fax. It typically involves the application of secure videoconferencing or store and forward technology to provide or support healthcare delivery by replicating the interaction of a traditional, encounter in person between a provider and a patient.7

“Telemedicine Technologies” means technologies and devices enabling secure electronic communications and information exchange between a licensee in one location and a patient in another location with or without an intervening healthcare provider.

6 American Medical Association, Council on Ethical and Judicial Affairs, Fundamental Elements of the Patient-Physician Relationship (1990), available at http://www.ama- assn.org/resources/doc/code-medical-ethics/1001a.pdf.

7 See Ctel.



Section Four. Guidelines for the Appropriate Use of Telemedicine Technologies in Medical Practice

The [Name of Board] has adopted the following guidelines for physicians utilizing telemedicine technologies in the delivery of patient care, regardless of an existing physician-patient relationship prior to an encounter:

Licensure:A physician must be licensed, or under the jurisdiction, of the medical board of the state where the patient is located. The practice of medicine occurs where the patient is located at the time telemedicine technologies are used. Physicians who treat or prescribe through online services sites are practicing medicine and must possess appropriate licensure in all jurisdictions where patients receive care.8

Establishment of a Physician-Patient Relationship:Where an existing physician-patient relationship is not present, a physician must take appropriate steps to es-tablish a physician-patient relationship consistent with the guidelines identified in Section Two, and, while each circumstance is unique, such physician-patient relationships may be established using telemedicine technolo-gies provided the standard of care is met.

Evaluation and Treatment of the Patient:A documented medical evaluation and collection of relevant clinical history commensurate with the presentation of the patient to establish diagnoses and identify underlying conditions and/or contra-indications to the treat-ment recommended/provided must be obtained prior to providing treatment, including issuing prescriptions, electronically or otherwise. Treatment and consultation recommendations made in an online setting, including issuing a prescription via electronic means, will be held to the same standards of appropriate practice as those in traditional (encounter in person) settings. Treatment, including issuing a prescription based solely on an online questionnaire, does not constitute an acceptable standard of care.

Informed Consent:Evidence documenting appropriate patient informed consent for the use of telemedicine technologies must be obtained and maintained. Appropriate informed consent should, as a baseline, include the following terms:

• Identification of the patient, the physician and the physician’s credentials;• Types of transmissions permitted using telemedicine technologies (e.g. prescription refills, appointment scheduling, patient education, etc.);• The patient agrees that the physician determines whether or not the condition being diagnosed and/or

treated is appropriate for a telemedicine encounter;• Details on security measures taken with the use of telemedicine technologies, such as encrypting data, password protected screen savers and data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures;• Hold harmless clause for information lost due to technical failures; and• Requirement for express patient consent to forward patient-identifiable information to a third party.

8 Federation of State Medical Boards, A Model Act to Regulate the Practice of Medicine Across State Lines (April 1996), available at http://www.fsmb.org/pdf/1996_grpol_telemedicine.pdf.



Continuity of Care:Patients should be able to seek, with relative ease, follow-up care or information from the physician [or phy-sician’s designee] who conducts an encounter using telemedicine technologies. Physicians solely providing services using telemedicine technologies with no existing physician-patient relationship prior to the encounter must make documentation of the encounter using telemedicine technologies easily available to the patient, and subject to the patient’s consent, any identified care provider of the patient immediately after the encounter.

Referrals for Emergency Services:An emergency plan is required and must be provided by the physician to the patient when the care provided us-ing telemedicine technologies indicates that a referral to an acute care facility or ER for treatment is necessary for the safety of the patient. The emergency plan should include a formal, written protocol appropriate to the services being rendered via telemedicine technologies.

Medical Records:The medical record should include, if applicable, copies of all patient-related electronic communications, includ-ing patient-physician communication, prescriptions, laboratory and test results, evaluations and consultations, records of past care, and instructions obtained or produced in connection with the utilization of telemedicine technologies. Informed consents obtained in connection with an encounter involving telemedicine technologies should also be filed in the medical record. The patient record established during the use of telemedicine technol-ogies must be accessible and documented for both the physician and the patient, consistent with all established laws and regulations governing patient healthcare records.

Privacy and Security of Patient Records & Exchange of Information:Physicians should meet or exceed applicable federal and state legal requirements of medical/health informa-tion privacy, including compliance with the Health Insurance Portability and Accountability Act (HIPAA) and state privacy, confidentiality, security, and medical retention rules. Physicians are referred to “Standards for Privacy of Individually Identifiable Health Information,” issued by the Department of Health and Human Services (HHS).9 Guidance documents are available on the HHS Office for Civil Rights Web site at: www.hhs.gov/ocr/hipaa.

Written policies and procedures should be maintained at the same standard as traditional face-to-face encoun-ters for documentation, maintenance, and transmission of the records of the encounter using telemedicine technologies. Such policies and procedures should address (1) privacy, (2) health-care personnel (in addition to the physician addressee) who will process messages, (3) hours of operation, (4) types of transactions that will be permitted electronically, (5) required patient information to be included in the communication, such as patient name, identification number and type of transaction, (6) archival and retrieval, and (7) quality oversight mecha-nisms. Policies and procedures should be periodically evaluated for currency and be maintained in an accessible and readily available manner for review.

Sufficient privacy and security measures must be in place and documented to assure confidentiality and integ-rity of patient-identifiable information. Transmissions, including patient e-mail, prescriptions, and laboratory

9 45 C.F.R. § 160, 164 (2000).



results must be secure within existing technology (i.e. password protected, encrypted electronic prescriptions, or other reliable authentication techniques). All patient-physician e-mail, as well as other patient-related electronic communications, should be stored and filed in the patient’s medical record, consistent with traditional record-keeping policies and procedures.

Disclosures and Functionality on Online Services Making Available Telemedicine Technologies:Online services used by physicians providing medical services using telemedicine technologies should clearly disclose:

• Specific services provided;• Contact information for physician;• Licensure and qualifications of physician(s) and associated physicians;• Fees for services and how payment is to be made; • Financial interests, other than fees charged, in any information, products, or services provided by a physician;• Appropriate uses and limitations of the site, including emergency health situations;• Uses and response times for e-mails, electronic messages and other communications transmitted via telemedicine technologies;• To whom patient health information may be disclosed and for what purpose;• Rights of patients with respect to patient health information; and• Information collected and any passive tracking mechanisms utilized.

Online services used by physicians providing medical services using telemedicine technologies should provide patients a clear mechanism to:

• Access, supplement and amend patient-provided personal health information;• Provide feedback regarding the site and the quality of information and services; and• Register complaints, including information regarding filing a complaint with the applicable state medical and osteopathic board(s).

Online services must have accurate and transparent information about the website owner/operator, location, and contact information, including a domain name that accurately reflects the identity.

Advertising or promotion of goods or products from which the physician receives direct remuneration, benefits, or incentives (other than the fees for the medical care services) is prohibited. Notwithstanding, online services may provide links to general health information sites to enhance patient education; however, the physician should not benefit financially from providing such links or from the services or products marketed by such links. When providing links to other sites, physicians should be aware of the implied endorsement of the information, services or products offered from such sites. The maintenance of preferred relationships with any pharmacy is prohibited. Physicians shall not transmit prescriptions to a specific pharmacy, or recommend a pharmacy, in exchange for any type of consideration or benefit form that pharmacy.



Prescribing:Telemedicine technologies, where prescribing may be contemplated, must implement measures to uphold pa-tient safety in the absence of traditional physical examination. Such measures should guarantee that the iden-tity of the patient and provider is clearly established and that detailed documentation for the clinical evaluation and resulting prescription is both enforced and independently kept. Measures to assure informed, accurate, and error prevention prescribing practices (e.g. integration with e-Prescription systems) are encouraged. To further assure patient safety in the absence of physical examination, telemedicine technologies should limit medication formularies to ones that are deemed safe by [Name of Board].

Prescribing medications, in-person or via telemedicine, is at the professional discretion of the physician. The indication, appropriateness, and safety considerations for each telemedicine visit prescription must be evaluated by the physician in accordance with current standards of practice and consequently carry the same professional accountability as prescriptions delivered during an encounter in person. However, where such measures are upheld, and the appropriate clinical consideration is carried out and documented, physicians may exercise their judgment and prescribe medications as part of telemedicine encounters.

Section Five. Parity of Professional and Ethical StandardsPhysicians are encouraged to comply with nationally recognized health online service standards and codes of ethics, such as those promulgated by the American Medical Association, American Osteopathic Association, Health Ethics Initiative 2000, Health on the Net and the American Accreditation HealthCare Commission (URAC).There should be parity of ethical and professional standards applied to all aspects of a physician’s practice. A physician’s professional discretion as to the diagnoses, scope of care, or treatment should not be limited or influenced by non-clinical considerations of telemedicine technologies, and physician remuneration or treatment recommendations should not be materially based on the delivery of patient-desired outcomes (i.e. a prescription or referral) or the utilization of telemedicine technologies.



REFERENCES

American Accreditation HealthCare Commission. Health Web Site Standards. July 2001.

AMA. Council on Ethical and Judicial Affairs. Code of Medical Ethics. 2000-2001.

AMA. Report of the Council on Medical Service. Medical Care Online. 4-A-01 (June 2001).

College of Physicians and Surgeons of Alberta. Policy Statement. Physician/Patient Relationships (February 2000).

Colorado Board of Medical Examiners. Policy Statement Concerning the Physician-Patient Relationship.

The Department of Health and Human Services, HIPPA Standards for Privacy of Individually Identifiable Health Informa-

tion. August 14, 2002.

FSMB. A Model Act to Regulate the Practice of Medicine Across State Lines. April 1996.

Health Ethics Initiative 2000. eHealth Code of Ethics. May 2000.

Health on the Net Foundation. Code of Medical Conduct for Medical and Health Web Sites. January 2000.

La. Admin. Code tit. 46, pt. XLV, § 7501-7521.

New York Board for Professional Medical Conduct. Statements on Telemedicine (draft document). October 2000.

North Carolina Medical Board. Position Statement. Documentation of the Physician-Patient Relationship. May 1,

1996.

Oklahoma Board of Medical Licensure. Policy on Internet Prescribing. November 2, 2000.

South Carolina Board of Medical Examiners. Policy Statement. Internet Prescribing. July 17, 2000.

Texas State Board of Medical Examiners. Internet Prescribing Policy. December 11, 1999.

Washington Board of Osteopathic Medicine and Surgery. Policy Statement. Prescribing Medication without Physician/

Patient Relationship. June 2, 2000.

©2014 Foley & Lardner LLP • Attorney Advertisement • Prior results do not guarantee a similar outcome • 321 N. Clark Street, Suite 2800, Chicago IL 60654 • 312.832.4500 • 14.10819

2014 Telemedicine SurveyExecutive Summary

November 2014

FOR MORE INFORMATION, VISIT US ONLINE AT FOLEY.COM1

As health care executives transform operations to comply with the Affordable Care Act, they are gearing up for the next monumental shift in the industry: telemedicine.

Technology has influenced nearly every sector of the economy, and the health care industry is following suit. Among telemedicine’s many benefits are the potential to exponentially expand a provider’s geographic footprint, use doctors’ time more efficiently and dramatically reduce the barriers to patient interaction.

Health care leaders tell us that their organizations are committed to continuing to implement telemedicine programs, even as they face challenges such as getting doctors to buy into the programs and insurers to pay for them. Why? For the majority of respondents, it’s simple — they believe telemedicine will help them keep patients healthier.

This report is based on feedback from health care leaders, the majority of whom are C-level executives from for-profit and nonprofit care providers, including hospitals, home health organizations and physician group practices. We asked them to evaluate the prospects for improved patient care and streamlined operations through telemedicine advancements, as well as regulatory hurdles and obstacles to reimbursement.

Executives Are Embracing TelemedicineTelemedicine is not a distant possibility; it is here and in play now. The vast majority of leaders (90 percent) report that their organizations have already begun developing or implementing a telemedicine program. Most also say that offering meaningful telemedicine services will be critical to the future success of their organizations.

» Eighty-four (84) percent of respondents felt that the development of telemedicine services is either very important (52 percent) or important (32 percent) to their organizations. Virtually none said they considered the technology to be unimportant (3 percent).

» While just 6 percent of respondents categorized their telemedicine programs as “mature,” only 8 percent said they had none at all. The remainders of responses are clustered somewhere in the middle: 34 percent are under consideration or in development, 18 percent are in the optimization phase, and the remaining 36 percent are being piloted or implemented.

» A majority of respondents already offer remote monitoring (64 percent), store and forward technology (54 percent), and real-time interaction capabilities (52 percent). Additionally, 39 percent say they have services that qualify as mHealth — patient-driven apps and online portals.

2014 Telemedicine Survey Executive Summary

http://www.foley.com/telemedicine/


The Affordable Care Act Is Driving Telemedicine AdvancementsThis attitude is partly due to the shift in financial and payment incentives under the ACA. As health care providers move from a fee-for-service model to one that reimburses based on positive patient outcomes, providers bear a greater share of the risk — and potential reward — for keeping their patients healthy. In addition, the level of responsibility shifts even more for providers in risk-bearing contracts or capitated arrangements, in which payments are made per person rather than per service. For executives under pressure to find cost-effective methods of engagement with their patients, telemedicine offers ways to streamline operations and create multiple touch points with patients, making it one of the most reliable methods for transitioning to a post-ACA, forward-looking reimbursement model.

» Executives are most excited about telemedicine’s potential to keep patients healthier. Half of respondents (50 percent) ranked improving the quality of care as their number one rationale for implementing telemedicine. Another 18 percent were most excited about reaching new patients.

» Despite the cost savings tied to telemedicine, health care leaders do not expect an immediate economic return on investment. A minimal percentage of respondents ranked the potential for increased revenue/profitability (11 percent) and getting a jump on the competition (4 percent) as their top motivators.

Reimbursement Is the Primary Obstacle to Implementation Although leaders fully endorsed the robust prospects of telemedicine, they were less confident about its immediate adoption. The widespread use of telemedicine requires doctors to be willing to transform the look and feel of the traditional, in-person patient visit. Meanwhile, the customary fee-for-service environment makes it challenging to be paid for medicine practiced outside the traditional spheres of interaction.

» Being paid for telemedicine remains an uphill battle, as indicated by 41 percent of respondents who said they are not reimbursed at all for telemedicine services, and 21 percent who reported receiving lower rates from managed care companies for telemedicine than for in-person care.

» Aside from reimbursement challenges, 48 percent of executives say they are more concerned with convincing doctors about the credibility of telemedicine than they are with convincing doctors that they will be adequately compensated for practicing it (36 percent).

» This uncertain environment led 87 percent of respondents to report that they do not believe a majority of their patients will be using any of their organization’s telemedicine services three years from now. Almost one-quarter said they anticipated fewer than 10 percent of their patients utilizing their organization’s services.



Executives Are Embracing TelemedicineOverwhelmingly, 84 percent of respondents indicated that the development of telemedicine services is either very important (52 percent) or important (32 percent) to their organizations. With this in mind, most are already piloting some suite of telemedicine products and more than half have developed some set of standards and guidelines to steer the implementation of services. A majority of respondents already offer remote monitoring (64 percent), store and forward technology (54 percent) and real-time interaction capabilities (52 percent).

Why do such a large majority of executives believe that the future success of their organizations is tied in part to telemedicine? From dramatically increasing a specialist’s geographic footprint to enabling chronic care management outside the hospital, telemedicine can transform an industry that is ripe for disruption. Nearly every other arena of the economy has been reshaped by technology, and medicine is catching the drift.



This excitement is reflected in a venture capital market whose interest in telemedicine technologies has grown significantly in recent years, including a $50 million funding round by eVisit firm Teladoc in September 2014. Teladoc’s competitor Doctor on Demand raised $21 million in August 2014. According to Mercom Capital Group, since 2010, the two quarters with the largest amount of funding raised for health care IT — a term synonymous with telemedicine — were Q2 and Q3 of 2014.

Indeed, many Americans already participate in telemedicine in ways they may not recognize. This gradual adoption is already enabling executives to embark on more ambitious projects that embrace technologies in ways less familiar to patients and doctors, such as teleconferencing between patient and provider. Deloitte predicts that in 2014, there will be as many as 75 million such visits in North America. As with all technologies, executives appear to think the growth curve is more likely to be exponential than linear.


http://venturebeat.com/2014/09/23/teladoc-raises-50-million-for-telemedicine-platform/

http://venturebeat.com/2014/09/23/teladoc-raises-50-million-for-telemedicine-platform/

http://mercomcapital.com/healthcare-it-sector-attracts-$956-million-in-vc-funding-in-q3-2014-reports-mercom-capital-group

http://www2.deloitte.com/content/dam/Deloitte/global/Documents/Technology-Media-Telecommunications/gx-tmt-2014prediction-evisits.pdf

http://www2.deloitte.com/content/dam/Deloitte/global/Documents/Technology-Media-Telecommunications/gx-tmt-2014prediction-evisits.pdf


The Affordable Care Act Is Driving Telemedicine Advancements

In the wake of the ACA, an ounce of prevention is now truly worth — in American dollars — a pound of cure. Models like capitation, in which a provider receives a flat fee per patient, and bundled payments, in which patients pay a one-time charge for a procedure, are moving out of the margins and into the mainstream.

Because the ACA penalizes hospitals for excessive numbers of readmissions and hospital-acquired conditions, health care executives are more focused on keeping their patients healthy, a priority supported by their primary reasons for implementing telemedicine services. When given a list of six possible motivations for adopting telemedicine, a full half of respondents said the improvement of the quality of care for patients was their number one rationale.

With its ability to multiply patient points of contact at a significantly

reduced cost, telemedicine enables physicians to keep closer tabs on their patients, whether it is monitoring blood pressure from a distance or ensuring day-to-day medication adherence. That is a primary reason why almost two-thirds of respondents said they already had remote monitoring programs in place, which allow providers to gather vital patient information and provide chronic care management remotely.

Simultaneously, telemedicine lowers the barriers to entry for patients to receive advice and support from medical professionals. The rural, the homebound and the elderly no longer have to make the trip to the office, and national experts can now weigh in on the maladies of patients from out of state using remote consultations. Executives charged with delivering both financial sustainability and their organizations’ social mission see these benefits and consequently embrace the patient-centered opportunities that telemedicine provides.


https://www.aamc.org/advocacy/medicare/153882/selected_medicare_hospital_quality_provisions_under_the_aca.html

https://www.aamc.org/advocacy/medicare/153882/selected_medicare_hospital_quality_provisions_under_the_aca.html


Reimbursement Is the Primary Obstacle to Implementation

When it comes to the spread of telemedicine, there remains a gulf between the aspirations and the regulatory environment. Even as the vast majority of executives endorse telemedicine as an important part of their future, 87 percent of respondents do not think the majority of their patients will be using their organizations’ telemedicine services three years from now, and almost a quarter say fewer than one in 10 patients will. There are a host of reasons for these concerns, but three stick out: trouble with reimbursement, a lack of physician buy-in and a regulatory landscape that is erratic at best.

Respondents were most disheartened by the difficulties of seeking and receiving reimbursement, with approximately half identifying these troubles as their primary obstacle to implementation. The

reality corresponds to the sentiment, as 41 percent said their organizations receive no reimbursement for a telemedicine visit. Another one in five said they received lower rates for telemedicine than in-person care from managed care companies.

Nor was the government’s rate of reimbursement sufficient to incentivize executives to roll out telemedicine on a broader scale. One in five indicated that Medicare’s thin coverage practices for telemedicine was their biggest reimbursement concern; 18 percent said they were most uneasy about state laws failing to mandate that commercial coverage companies pay for telemedicine services. Compounding these concerns are several restrictions that fuel the pessimistic outlook respondents harbor. Primary among them is the requirement that a provider obtain licensure in whatever state he or she provides telemedicine services. Internal concerns abound as well, from the need to amend existing corporate structures to the necessity of building supervisory structures that will mitigate the potential for fraud and abuse.



The medical boards of Georgia and Florida are the latest to provide a set of guidelines for the practice of responsible telemedicine. In September 2014, California enacted a law that loosened the consent requirements for practicing telemedicine. However, the ultimate solution for both a legal and reimbursement framework will likely be a federal one. There is hope in Washington: According to the American Telemedicine Association, there are 55 pieces of legislation pending that will address telemedicine in one way or another. The most comprehensive of these, the Medicare Telehealth Parity Act, was introduced this summer.

Physicians have a reputation for being slow adopters to new avenues of care — particularly to those that they see as untested. Our survey shows that telemedicine is no different. Almost half of those surveyed worried that physicians would not regard telemedicine as a credible and high-quality supplement to their practice. Given the visceral differences between palpating a patient in the examination room and chatting about symptoms through a laptop camera, health care providers will have to work to make their doctors comfortable with new technology.


http://www.foley.com/Georgia-Composite-Medical-Board-Issues-New-Telemedicine-Rules-08-20-2014

http://www.foley.com/Florida-Board-of-Medicine-Issues-Telemedicine-Regulations-05-15-2014

http://www.beckershospitalreview.com/healthcare-information-technology/new-califonia-law-makes-it-easier-for-patients-to-use-telemedicine.html

http://www.americantelemed.org/docs/default-source/policy/113th-congress-bills0D169E2017A9B17100A7C38A553C5F8307973BF86123E22E8229D71030AAE2B83222AFA2CBC93FD13EA66DF3D7E5A1AB1DEDEF92E02F3C162B624062.pdf?sfvrsn=15

http://www.americantelemed.org/docs/default-source/policy/113th-congress-bills0D169E2017A9B17100A7C38A553C5F8307973BF86123E22E8229D71030AAE2B83222AFA2CBC93FD13EA66DF3D7E5A1AB1DEDEF92E02F3C162B624062.pdf?sfvrsn=15

http://www.foley.com/intelligence/detailpdf.aspx?int=5efd2c96-919e-4bea-adf7-a33c098631fa


Questions about reimbursement and physician support do a lot to account for why half of respondents reported that their telemedicine programs were in the earliest stages — 34 percent that were still pre-operational, with 16 percent in the pilot phase.



Methodology and Demographics Foley distributed the 2014 Telemedicine Survey to health care executives throughout the United States in September and October 2014. The survey was completed by 57 executives, and results were tabulated, analyzed and released in November 2014.

Respondents

» C-suite executives – 34 percent

» Director, vice president, or manager – 34 percent

» Administrator – 11 percent

» In-house attorneys/corporate counsel – 11 percent

» Other professionals – 10 percent

Health Care Organizations — Types

» Non-profit hospitals – 44 percent

» Provider groups – 13 percent

» Long-term care management – 11 percent

» For-profit hospitals – 8 percent

» Physician group practices – 6 percent

For More InformationTo learn more about Foley’s Telemedicine Survey, please contact Linda Yun at 312.832.4755 or [email protected], or Ashley Hutchinson at 312.832.5789 or [email protected].

» Managed care – 4 percent

» Municipal hospitals – 4 percent

» Other (medical assistance, service provider and etc.) – 10 percent

Health Care Organizations — Size

» More than 10,000 full-time employees – 19 percent

» More than 1,000 full-time employees – 28 percent

» Between 501 – 1,000 full-time employees – 20 percent

» Between 101 – 500 full-time employees – 11 percent

» Between 1 – 100 full-time employees – 22 percent


mailto:lyun%40foley.com?subject=2014%20Telemedicine%20Survey

mailto:ahutchinson%40foley.com?subject=2014%20Telemedicine%20Survey

of 13

《国家卫生计生委关于推进医疗机构远程医疗服务的意见》

的解读

An Interpretation of the Opinions of the National Health andFamily Planning Commission Regarding the Promotion of the

Medical Institution Telemedicine Services

中华人民共和国国家卫生和计划生育委员会 2014-08-29

The National Health and Family Planning Commission of thePeople’s Republic of China

August 29, 2014

PRESENTED BY:

Tad FerrisPartnerFoley & Lardner [email protected]

Nathaniel LacktmanPartnerFoley & Lardner [email protected]

of 13

依托信息化技术开展远程医疗服务，是提高基层医疗服务水平，解决基层和边远地区人民群众看

病就医问题的有效途径之一。中共中央、国务院《关于深化医药卫生体制改革的意见》、《卫生

事业发展“十二五”规划》和《国务院关于促进信息消费扩大内需的若干意见》等文件都对此提

出了明确要求。

Performance of telemedicine services by relying on information technologies is one of the effective waysto improve the level of medical services at the grassroots level and resolve the problem of medical carefor members of the public at the grassroots level and in remote areas. Documents including OpinionsRegarding the Deepening of the Reforms of the Medical and Health System, The 12th Five-Year Plan forthe Development of the Health Cause and Several Opinions of the State Council Regarding theConsumption of Information and Expansion of the Domestic Demand have all set forth clearrequirements in this regard.

2010 年以来，中央财政投入 8428 万元，支持 22个中西部省份和新疆生产建设兵团建立了基层远

程医疗系统，并安排 12所原卫生部部属（管）医院与 12 个西部省份建立高端远程会诊系统，共

纳入 12 所原部属（管）医院、98所三级医院、3所二级医院和 726 所县级医院，有力推动了远程

医疗的发展。根据我委 2013 年的统计，全国开展远程医疗服务的医疗机构共计 2,057 所。

Since 2010, the financial authorities of the central government have invested ¥84.28 million Yuan, insupporting 22 Midwestern provinces and Xinjiang Production and Construction Corp. in setting uptelemedicine systems and in making arrangements for 12 hospitals originally subject to the jurisdiction(control) of the Ministry of Health to set up high-end remote diagnosis systems with 12 Midwesternprovinces. A total of 12 hospitals originally subject to the jurisdiction (control) of the Ministry of Health,98 hospitals at level 3, 3 hospitals at level 2 and 726 county level hospitals have been included, thusgiving a vigorous promotion to the development of telemedicine services. Nationwide, the total numberof medical institutions performing telemedicine services is 2,057.

随着远程医疗服务的广泛应用，国家层面需要对远程医疗的管理规范、实施程序、责任认定、监

督管理等作出明确规定，以促进其健康发展。原卫生部 1999 年 1月 4 日印发的《关于加强远程医

疗会诊管理的通知》（卫办发〔1999〕2号），主要规范的是远程会诊管理。随着技术的进步，

远程医疗服务的范围已经有了很大扩展，远程病理诊断、远程影像诊断、远程监护等新的远程医

疗服务项目得到比较广泛的应用，原有的管理要求已经不能适应当前远程医疗服务发展的实际要

求。为推动远程医疗服务持续健康发展，优化医疗资源配置，实现优质医疗资源下沉，国家卫生

计生委制定了《关于推进医疗机构远程医疗服务的意见》（以下简称《意见》）。

In order to utilize the telemedicine services more effectively at the State level, clear provisions areneeded for management, regulations, implementing procedures, identifying responsibilities andsupervision of telemedicine services to promote their healthy development. The Notice on Reinforcingthe Administration of Telemedicine, printed and issued on January 4, 1999 by the former Ministry of

Health (Health Office Issue 〔1999〕Number 2), mainly regulates the management of remote diagnosis.With more advanced technologies, the scope of telemedicine services has been greatly expanded. New

一、起草背景I. Background of the draft

of 13

telemedicine service items, such as remote pathological diagnosis, remote imaging diagnosis andremote monitoring, etc., have been used widely. The original managerial requirements no longer meetthe actual requirements of the current development in telemedicine services. To promote the sustainedhealthy development of telemedicine services, optimize the allocation of medical resources and achievethe goal of providing quality medical services resources to the grassroots level, the National Health andFamily Planning Commission has prepared the Opinions Regarding the Promotion of Medical InstitutionTelemedicine Services (hereinafter referred to as “The Opinions.”

of 13

《意见》分为 4 个部分，其主要内容如下：

The Opinions are divided into 4 parts and its major items are as follows:

（一）积极推动远程医疗服务发展。

(I) Actively promote the development of telemedicine services.

地方各级卫生计生行政部门要将远程医疗服务体系建设纳入区域卫生规划和医疗机构设置规划，

积极协调同级财政部门为远程医疗服务的发展提供相应的资金支持和经费保障，协调发展改革、

物价、人力资源社会保障等相关部门，为远程医疗服务的发展营造适宜的政策环境。

Administrative authorities in charge of health and family planning at various local levels should includethe construction of a telemedicine service system in their regional health plan and medical institutionsetup plan, actively coordinate with financial authorities at the same level in order to provideappropriate funding, support and safeguarding for the development of telemedicine services andcoordinate with relevant authorities, including reforms, pricing, human resources and Social Security,etc. in order to create an appropriate policy environment for the development of telemedicine services.

（二）确保远程医疗服务质量安全。

(II) Ensure the quality and safety of telemedicine services.

一是明确了远程医疗服务的定义和内容：一方医疗机构邀请其他医疗机构，运用通讯、计算机及

网络技术，为本医疗机构诊疗患者提供技术支持的医疗活动。其项目主要包括：远程病理诊断、

远程医学影像诊断、远程监护、远程会诊、远程门诊、远程病例讨论等。 First, clarify the definition and content of telemedicine services: on one hand, medical institutions inviteother medical institutions in using communications, computer and network technologies to providemedical activities in the diagnosis and treatment of patients of their own medical institutions withtechnical support. Their products mainly include: remote pathological diagnosis, diagnostic imagingmonitoring, consultations, outpatient services and case discussions, etc.

二是要求医疗机构在开展远程医疗服务过程中严格遵守相关法律、法规、信息标准和技术规范，

确保医疗质量安全，维护患者合法权益。非医疗机构不得开展远程医疗服务。

Second, during the performance of telemedicine services, medical institutions are required to strictlycomply with the applicable laws, regulations, information standards and technical practices, ensuringthe quality and safety of medical services and protecting the legal interest of patients. Non-medicalinstitutions are not authorized to provide telemedicine services.

二、主要内容II. Major items

of 13

（三）完善远程医疗服务流程。

(III) Perfect telemedicine service processes.

一是要求开展远程医疗服务的医疗机构具备相应的诊疗科目及人员、技术、设备、设施条件，签

订远程医疗合作协议，约定远程医疗流程、权利义务、医疗损害风险和责任分担等事项，并取得

患者知情同意。

First, medical institutions that perform telemedicine services are required to have appropriatediagnostic and treatment departments, personnel, technologies, equipment facilities, executetelemedicine cooperation agreements and covenant items, including telemedicine service processes,rights and obligations and the sharing of medical harm risks and responsibilities, etc., and obtain theinformed consent of patients.

二是要求开展远程医疗服务的医疗机构完善远程医疗服务流程，并认真做好组织实施。医疗机构

要按照病历书写及保管有关规定共同完成病历资料。

Second, medical institutions that undertake telemedicine services are required to perfect theirtelemedicine service processes and conscientiously organize their implementation. Medical institutionsshould jointly complete medical records information in accordance with the relevant provisions for thewriting and safekeeping of medical records.

（四）加强远程医疗服务监督管理。

(IV) Enhance the supervision and management of telemedicine services.

一是要规范机构名称。未经国家卫生计生委核准，任何开展远程医疗服务的医疗机构，不得冠以

“中国”、“中华”、“全国”及其他指代、暗含全国或者跨省（自治区、直辖市）含义的名称。

First, standardize names of the institutions. Without the approval of the National Health and FamilyPlanning Commission, no medical institution performing telemedicine services shall include in theirnames “China,” “Chinese” and “National” and other alternative names or names that imply a nationwideor interprovincial (inter-autonomous regions and cities subject to the direct jurisdiction of the centralgovernment) scope.

二是要控制安全风险。医疗机构在开展远程医疗服务过程中，主要专业技术人员或者关键设备、

设施及其他辅助条件发生变化，不能满足远程医疗服务需要，或者存在医疗质量和医疗安全隐患，

以及出现与远程医疗服务直接相关严重不良后果时，须立即停止远程医疗服务并按规定报告。

Second, safety control risks. During the performance of telemedicine services by medical institutions,any change of key professional and technical personnel or key equipment, facilities and other supportingconditions, which makes it impossible to meet the need for the telemedicine services or if there existsany hazards with the quality of medical services and medical safety and upon the occurrence of seriousadverse consequences directly related to telemedicine services, telemedicine services should bestopped immediately and a report shall be filed in accordance with the applicable provisions.

三是要加强日常监管。地方各级卫生计生行政部门在监督检查过程中发现存在远程医疗服务相关

的医疗质量安全隐患或者接到相关报告时，要及时组织对医疗机构远程医疗服务条件的论证，经

论证不具备远程医疗服务条件的，要提出整改措施，在整改措施落实前不得继续开展远程医疗服

务。

of 13

Third, enhance daily supervision. When administrative authorities at various local levels in charge ofhealth and family planning discover hazards that exist with the quality and safety of medical servicesrelated to telemedicine services, they should immediately conduct an investigation, and verification ofany issues with proof. Upon such an investigation, if the conditions are not adequately improved toprovide telemedicine services, corrective actions should be proposed and prior to the execution of suchcorrective actions, and telemedicine service is not permitted to continue.

四是要依法依规处理。在远程医疗服务过程中发生医疗争议时，由邀请方和受邀方按照相关法律、

法规和双方达成的协议进行处理，并承担相应的责任。医务人员直接向患者提供远程医疗服务的，

由其所在医疗机构按照相关法律、法规规定，承担相应责任。医疗机构和医务人员在开展远程医

疗服务过程中，有违反法律、法规行为的，由卫生计生行政部门按照有关法律、法规规定处理。

Fourth, handle the matter in accordance with laws and regulations. Upon the occurrence of any medicaldispute during the performance of telemedicine services, the host and the invited party shall handle thematter in accordance with the applicable laws and regulations and the agreement reached by andbetween the parties and undertake the appropriate responsibilities. When medical personnel directlyprovide telemedicine services to patients, their medical institutions should undertake the appropriateresponsibility in accordance with the provisions of applicable laws and regulations. In the event thatmedical institutions and medical personnel engage in actions that violate laws and regulations duringthe process of the performance of telemedicine services, the administrative authorities in charge ofhealth and family planning should deal with the same in accordance with the provisions of applicablelaws and regulations.

此外，医疗机构之间运用信息化技术，在一方医疗机构使用相关设备，精确控制另一方医疗机构

的仪器设备（如手术机器人）直接为患者进行实时操作性的检查、诊断、治疗、手术、监护等医

疗活动，其管理办法和相关标准规范由我委另行制定。医疗机构与境外医疗机构之间开展远程医

疗服务的，参照本意见执行。

In addition, when information technology is used among medical institutions, whereby one medicalinstitution uses the relevant equipment to precisely control the instruments and equipment (such as asurgical robot) of another medical institution to directly perform medical activities, such as anexamination, diagnosis, treatment, real-time operational surgery and monitoring, the managementmeasures and relevant standards and regulations therefore will be separately prepared by ourCommission. When telemedicine services are performed between [Chinese] medical institutions andmedical institutions outside of our country, reference should be made to The Opinions.

相关链接：国家卫生计生委关于推进医疗机构远程医疗服务的意见

Relevant link[/Attachment]: Opinions of the National Health and Family Commission Regarding thePromotion of Medical Institution Telemedicine Services

[See next page for Attachment translation.]

of 13

Attachment

国家卫生计生委关于推进医疗机构远程医疗服务的意见

Opinions of the National Health and Family PlanningCommission Regarding the Promotion of Medical Institution

Telemedicine Services

中华人民共和国国家卫生和计划生育委员会 2014-08-29

The National Health and Family Planning Commission of thePeople’s Republic of China

August 29, 2014

国卫医发〔2014〕51 号

National Health Medical Issue 〔2014〕 Number 51

各省、自治区、直辖市卫生厅局（卫生计生委），新疆生产建设兵团卫生局：

To the Health Departments and Bureaus (Health and Family Planning Commissions of various provinces,autonomous regions and cities under the direct jurisdiction of the central government) and the Health

Bureau of Xinjiang Production and Construction Corp:

为推动远程医疗服务持续健康发展，优化医疗资源配置，实现优质医疗资源下沉，提高医疗服务

能力和水平，进一步贯彻落实《中共中央国务院关于深化医药卫生体制改革的意见》，现就推进

医疗机构远程医疗服务提出以下意见：

To promote the sustained and healthy development of telemedicine services, optimize the allocation ofmedical resources, achieve the goal of providing quality medical services resources to the grassroots

level, improve the capability and level of medical services and further implement and execute theOpinions of the Central Committee of the Chinese Communist Party and the State Council regarding the

Deepening of the Reforms of the Medical and Health Systems, the following Opinions are herebyproposed in the initiative for the improvement of telemedicine services by medical institutions:

of 13

地方各级卫生计生行政部门要将发展远程医疗服务作为优化医疗资源配置、实现优质医疗资源下

沉、建立分级诊疗制度和解决群众看病就医问题的重要手段积极推进。将远程医疗服务体系建设

纳入区域卫生规划和医疗机构设置规划，积极协调同级财政部门为远程医疗服务的发展提供相应

的资金支持和经费保障，协调发展改革、物价、人力资源社会保障等相关部门，为远程医疗服务

的发展营造适宜的政策环境。鼓励各地探索建立基于区域人口健康信息平台的远程医疗服务平台。

Administrative authorities at various local levels in charge of health and family planning should activelypromote the improvement of the quality of telemedicine services as an important means of optimizingof the allocation of medical resources, achieve the goal of providing quality medical services resourcesto the grassroots level, setting up diagnostic and treatment systems at various levels and resolving theissue of medical diagnosis and treatment for members of the public. [Such authorities should also]include construction of a telemedicine service system in their regional health plan and medicalinstitution setup plan, actively coordinate with financial authorities at the same level in order to provideappropriate funding and support and safeguards for the development of telemedicine services andcoordinate with [other] relevant authorities, including reforms, pricing, human resources and SocialSecurity, etc., in order to create an appropriate policy environment for the development of telemedicineservices. [In addition, they should] encourage various locales to explore the setup of platforms forprovision of telemedicine services based on the health information platform of the regional populations.

一、加强统筹协调，积极推动远程医疗服务发展I. Enhance overall coordination and actively promotethe development of telemedicine services

of 13

（一）远程医疗服务内容。远程医疗服务是一方医疗机构（以下简称邀请方）邀请其他医疗机构

（以下简称受邀方），运用通讯、计算机及网络技术（以下简称信息化技术），为本医疗机构诊

疗患者提供技术支持的医疗活动。医疗机构运用信息化技术，向医疗机构外的患者直接提供的诊

疗服务，属于远程医疗服务。远程医疗服务项目包括：远程病理诊断、远程医学影像（含影像、

超声、核医学、心电图、肌电图、脑电图等）诊断、远程监护、远程会诊、远程门诊、远程病例

讨论及省级以上卫生计生行政部门规定的其他项目。

(I) Telemedicine service items. Telemedicine services are medical activities whereby the medicalinstitutions of one party (hereinafter referred to as the host) invite other medical institutions(hereinafter referred to as the invited parties) to use communications, computer and networktechnologies (hereinafter referred to as information technologies) to provide technical support in thediagnosis and treatment of patients in their own institutions. Diagnostic and treatment servicesprovided by medical institutions using information technologies directly to patients outside their ownmedical institutions are telemedicine services. Telemedicine service items include: remote pathologicaldiagnosis, remote medical imaging (including imaging, ultrasound, nuclear medicine, electrocardiograms,electromyography and electroencephalograms, etc.) diagnosis, remote monitoring, remoteconsolidations, remote outpatient services and remote case discussions and other items provided byadministrative authorities above the provincial levels in charge of health and family planning.

（二）遵守相关管理规范。医疗机构在开展远程医疗服务过程中应当严格遵守相关法律、法规、

信息标准和技术规范，建立健全远程医疗服务相关的管理制度，完善医疗质量与医疗安全保障措

施，确保医疗质量安全，保护患者隐私，维护患者合法权益。非医疗机构不得开展远程医疗服务。

(II) Comply with the relevant management regulations. During the process of the performance oftelemedicine services, medical institutions should strictly comply with the applicable laws, regulations,information standards and technical practices, [have in place] a complete professional managementsystem related to telemedicine services, perfect medical service quality and medical safety safeguards,ensure the quality and safety of medical services and protect the privacy of patients and the legitimateinterest of patients. Non-medical institutions are not permitted to perform telemedicine services.

二、明确服务内容，确保远程医疗服务质量安全

II. Clarify service items and ensure the quality andsafety of telemedicine services

of 13

（一）具备基本条件。医疗机构具备与所开展远程医疗服务相适应的诊疗科目及相应的人员、技

术、设备、设施条件，可以开展远程医疗服务，并指定专门部门或者人员负责远程医疗服务仪器、

设备、设施、信息系统的定期检测、登记、维护、改造、升级，确保远程医疗服务系统（硬件和

软件）处于正常运行状态，符合远程医疗相关卫生信息标准和信息安全的规定，满足医疗机构开

展远程医疗服务的需要。

(I) Possess the basic conditions. Medical institutions have the diagnostic and treatment subjectsbefitting the performance of telemedicine services and corresponding personnel, technologies,equipment and facilities and conditions, can perform telemedicine services and designate dedicateddepartments or personnel that are responsible for the regular tests, registrations, maintenance,modifications and upgrades of the instruments, equipment, facilities and information systems used intelemedicine services, to ensure that telemedicine service systems (hardware and software) are instandard operation, meet the relevant health information standards and information security provisionsrelated to telemedicine services and meet the needs for medical institutions in performing theirtelemedicine services.

（二）签订合作协议。医疗机构之间开展远程医疗服务的，要签订远程医疗合作协议，约定合作

目的、合作条件、合作内容、远程医疗流程、双方权利义务、医疗损害风险和责任分担等事项。

(II) Execute a cooperation agreement. When medical institutions perform telemedicine services amongthemselves, they should execute a cooperation agreement on telemedicine services and covenant itemssuch as the purpose of a cooperation, conditions of cooperation, processes of telemedicine services, therights and obligations of the parties and the sharing of the risks of medical harm and responsibilities.

（三）患者知情同意。邀请方应当向患者充分告知并征得其书面同意，不宜向患者说明的，须征

得其监护人或者近亲属书面同意。

(III) Informed consent of patients. The host should fully inform patients and seek their written consent.When it is not appropriate to offer an explanation to the patient [e.g., in minor patient situations], thewritten consent of the guardian or a close relative of patients should be sought.

（四）认真组织实施。邀请方需要与受邀方通过远程医疗服务开展个案病例讨论的，需向受邀方

提出邀请，邀请至少应当包括邀请事由、目的、时间安排，患者相关病历摘要及拟邀请医师的专

业和技术职务任职资格等。受邀方接到远程医疗服务邀请后，要及时作出是否接受邀请的决定。

接受邀请的，须告知邀请方，并做好相关准备工作；不接受邀请的，及时告知邀请方并说明理由。

(IV) Conscientiously organize implementation. When the host needs to engage in a discussion ofindividual cases in the performance of telemedicine services, it needs to submit an invitation to theinvited party. The invitation should at least include the cause of action, purpose of the invitation, theschedule, excerpts of the relevant medical records of the patient and the professional and technical

三、完善服务流程，保障远程医疗服务优质高效 III. Perfect the service process and ensure the highquality and efficiency of telemedicine services

of 13

positions and competency qualifications of the physicians proposed for the invitation. After receiving aninvitation for telemedicine services, the invited party should promptly make a decision as to whether toaccept such an invitation. If it accepts such an invitation, it must notify the host and properly performthe relevant preparatory work; if it does not accept the invitation, it should promptly notify the host andexplain the reasons.

受邀方应当认真负责地安排具备相应资质和技术能力的医务人员，按照相关法律、法规和诊疗规

范的要求，提供远程医疗服务，及时将诊疗意见告知邀请方，并出具由相关医师签名的诊疗意见

报告。邀请方具有患者医学处置权，根据患者临床资料，参考受邀方的诊疗意见作出诊断与治疗

决定。

The invited party should conscientiously and responsibly arrange for medical personnel with appropriatequalifications and technical abilities to provide telemedicine services in accordance with therequirements of applicable laws, regulations and diagnostic practices, promptly inform the host of thediagnostic opinions and issue diagnostic opinions and reports signed by the relevant physicians. The hosthas the right of medical disposal with respect to the patients and should, based on the clinicalinformation on the patients and with reference to the diagnostic opinions of the invited party, makediagnostic and treatment decisions.

（五）妥善保存资料。邀请方和受邀方要按照病历书写及保管有关规定共同完成病历资料，原件

由邀请方和受邀方分别归档保存。远程医疗服务相关文书可通过传真、扫描文件及电子签名的电

子文件等方式发送。

(V) Properly maintain records. The host and the invited party should jointly complete medical recordinformation in accordance with the provisions related to the writing and safekeeping of medical records.The original copies should be separately filed by the host and invited party respectively. Documentsrelated to telemedicine services can be sent by fax, scanned and electronically signed for electronic filing.

（六）简化服务流程。邀请方和受邀方建立对口支援或者其他合作关系，由邀请方实施辅助检查，

受邀方出具相应辅助检查报告的，远程医疗服务流程由邀请方和受邀方在远程医疗合作协议中约定。

(VI) Simplify the service process. The host and the invited party should set up matching support oranother kind of partnership relationship. Where the host implements auxiliary examinations and theinvited party issues corresponding auxiliary examination reports, the telemedicine service processshould be covenanted by and between the host and invited party in the telemedicine cooperationagreement.

（七）规范人员管理。医务人员向本医疗机构外的患者直接提供远程医疗服务的，应当经其执业

注册的医疗机构同意，并使用医疗机构统一建立的信息平台为患者提供诊疗服务。

(VII) Standardize personnel management. In the event that medical personnel provide telemedicineservices directly to patients outside their own medical institutions, the consent of the medicalinstitutions where they are registered to practice should be obtained and the information platformcentrally set up by the medical institutions should be used to provide diagnostic and treatment servicesfor patients.

of 13

（一）规范机构名称。各级地方卫生计生行政部门要加强对远程医疗服务的监督管理。未经我委

核准，任何开展远程医疗服务的医疗机构，不得冠以“中国”、“中华”、“全国”及其他指代、

暗含全国或者跨省（自治区、直辖市）含义的名称。

(I) Standardize names of the institutions. Administrative authorities in charge of family planning shouldenhance supervision and management of telemedicine services. Without the approval of ourCommission, no medical institution performing telemedicine services should include in their name“China,” “Chinese” and “National” and other alternative names or names that imply a nationwide orinterprovincial (inter-autonomous regions and cities subject to the direct jurisdiction of the centralgovernment) scope.

（二）控制安全风险。医疗机构在开展远程医疗服务过程中，主要专业技术人员或者关键设备、

设施及其他辅助条件发生变化，不能满足远程医疗服务需要，或者存在医疗质量和医疗安全隐患，

以及出现与远程医疗服务直接相关严重不良后果时，须立即停止远程医疗服务，并按照《医疗质

量安全事件报告暂行规定》的要求，向核发其《医疗机构执业许可证》的卫生计生行政部门报告。

(II) Control safety risks. During the process of the performance of telemedicine services by medicalinstitutions, in case of any change to key professional and technical personnel or key equipment,facilities and other supporting conditions, which makes it impossible to meet the need for telemedicineservices or if there exists any hazards with the quality of medical services and medical safety and uponthe occurrence of serious adverse consequences directly related to the telemedicine services,telemedicine services should be stopped immediately and a report should be filed with theadministrative authorities in charge of health and family planning that have issued License of a MedicalInstitution for Practice thereto in accordance with the requirements of Interim Provisions for ReportingMedical Service Quality and Safety Incidents.

（三）加强日常监管。地方各级卫生计生行政部门在监督检查过程中发现存在远程医疗服务相关

的医疗质量安全隐患或者接到相关报告时，要及时组织对医疗机构远程医疗服务条件的论证，经

论证不具备远程医疗服务条件的，要提出整改措施，在整改措施落实前不得继续开展远程医疗服

务。

(III) Enhance daily supervision. When administrative authorities at various local levels in charge ofhealth and family planning discover hazards that exist with the quality and safety of medical servicesrelated to telemedicine services, they should immediately organize an investigation and verification withproof by medical institutions. Upon such an investigation, if the conditions are not adequately improvedto provide telemedicine services, corrective actions should be proposed and prior to the execution ofsuch corrective actions, performance of telemedicine services should not continue.

四、加强监督管理，保证医患双方合法权益IV. Enhance supervision and management andguarantee the legitimate interests of both physiciansand patients

of 13

（四）依法依规处理。在远程医疗服务过程中发生医疗争议时，由邀请方和受邀方按照相关法律、

法规和双方达成的协议进行处理，并承担相应的责任。医务人员直接向患者提供远程医疗服务的，

由其所在医疗机构按照相关法律、法规规定，承担相应责任。医疗机构和医务人员在开展远程医

疗服务过程中，有违反《执业医师法》、《医疗机构管理条例》、《医疗事故处理条例》和《护

士条例》等法律、法规行为的，由卫生计生行政部门按照有关法律、法规规定处理。

(IV) Handle the matter in accordance with laws and regulations. Upon the occurrence of any medicaldispute during the performance of telemedicine services, the host and the invited parties should handlethe matter in accordance with the applicable laws and regulations and the agreement concluded by andbetween the parties and undertake appropriate responsibilities. When medical personnel directlyprovide telemedicine services to patients, their medical institutions should undertake appropriateresponsibility in accordance with the provisions of applicable laws and regulations. In the event thatmedical institutions and medical personnel engage in actions that violate laws and regulations, includingthe Law of Practicing Physicians, Management Regulations of Medical Institutions, Regulations for theHandling of Medical Accidents and Nurse Regulations, etc., during the process of the performance oftelemedicine services, the administrative authorities in charge of health and family planning should dealwith the same in accordance with the provisions of applicable laws and regulations.

医疗机构之间运用信息化技术，在一方医疗机构使用相关设备，精确控制另一方医疗机构的仪器

设备（如手术机器人）直接为患者进行实时操作性的检查、诊断、治疗、手术、监护等医疗活动，

其管理办法和相关标准规范由我委另行制定。医疗机构与境外医疗机构之间开展远程医疗服务的，

参照本意见执行。执行过程中有关问题，请及时与我委医政医管局联系。

When information technology is used among medical institutions, whereby one medical institution usesthe relevant equipment to precisely control the instruments and equipment (such as a surgical robot) ofanother medical institution to directly perform medical activities, such as examination, diagnosis,treatment, real-time operational surgery and monitoring, the management measures and relevantstandards and regulations therefore will be separately prepared by our Commission. When telemedicineservices are performed between medical institutions and medical institutions outside our country,reference should be made to The Opinions. For any issue during the implementation process, pleasecontact Medical Administration and Medical Control Bureau of our Commission in a timely manner.

联系人：范晶、焦雅辉

Contact persons: Fan Jing and Jiao Yahui

联系电话：010-68792791、68791888

Contact phone numbers: 010 - 68792791, 68791888

国家卫生计生委

National Health and Family Planning Commission

2014 年 8 月 21 日

August 21, 2014